General Data Name: Y.F. Age & Gender: 67/Female Civil Status: Widow Occupation: Housewife Chief Complaint: Left neck pain

History of Present Illness Localized left neck pain, graded 3/10 Characterized as stiffness, constant and non- progressive Precipitated on lateral flexion of the neck to the left and right Slightly relieved by application of Salonpas ointment and massage No weakness, swelling, numbness and tingling No associated event prior to said symptom No limitation with ADL Slight limitation in doing household chores June 30, 2010

History of Present Illness Persistence of symptoms prompted consult at UST OPD Medicine – Cervical spine Xray (AP, Lateral view) was requested – Unrecalled medication prescribed – Referred to Rehabilitation Medicine OPD 1 day PTA CONSULT

Cervical Spine Radiograph Alignment is satisfactory Vertebral height is preserved Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

Cervical Spine Radiograph Impression: Alignment is satisfactory Vertebral height is preserved

Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

Cervical Spine Radiograph Impression: Minimal osteophytes are seen in the cervical vertebral bodies There is a slight narrowing of the disk space at C5-C6, C6-C7 The rest of the study is unremarkable

Review of Systems (-) wt loss, anorexia, weakness, fatigue, insomnia (-) itchiness, pigmentation, rash, active dermatoses (-) blurring of vision, redness, itchiness, Iacrimation (-) deafness, tinnitus, aural discharge (-) anosmia, epistaxis, sinusitis, nasal discharge (-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion (-) breast masses, discharge, trauma (-) dyspnea, cough, hemoptysis, (-) easy fatigability, chest pain, nocturnal dyspnea, palpitation, syncope, edema (-) phlebitis, varicosities, claudication (-) dyshpagia, nausea, vomiting, retching, hematemesis, melena, hematochezia, belching, indigestion, diarrhea, constipation (-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia, urethral (-) joint stiffness, joint pain, muscle pain, cramps (-) heat-cold intolerance, polydipsia, polyphagia, polyuria (-) headache, seizures, anxiety, depression, IPR difficulties

Past Medical History Previous Surgery/Hospitalization – none Major Adult Illnesses - Rheumatoid Arthritis (2000), Diclofenac mg taken for 5 years Immunizations: unrecalled Medications/supplements: none Allergies: none

Family History (+) Arthritis: sister (-) HPN, DM, Heart disease, Asthma, PTB, Cancer, Thyroid disorder

Personal and Social History Mixed diet (vegetables, fish & fruits) Non smoker, Non alcohol beverage drinker Denies illicit drug use Housewife, lives with her 2 sons Does all the household chores Does stretching exercise everyday Sleeps at around 8 hours/day

Physical Examination General Survey: Conscious, coherent, ambulatory, not in cardiorespiratory distress Vital Signs: BP 110/70mmHg PR 76bpm, regular RR 14cpm, regular T 36,4 o C Height: 5’4”ft Weight: 48kg BMI: 18

Physical Examination on Admission Head and Neck: Warm dry skin, no skin changes, pink palpebral conjunctiva, anicteric sclera, midline septum, moist buccal mucosa, nonhyperemic pharyngeal wall, tonsils not enlarged, no tragal tenderness Chest: Symmetrical chest expansion, Resonant, Clear breath sounds Heart: Adynamic precordium, apex beat at 5 th LICS, MCL, no lifts, no heaves, no thrills, S1>S2 at the apex, S2>S1 at the base, (-) S3, (-) murmurs Abdomen: Flabby abdomen, normoactive bowel sounds, no tenderness Extremities: no deformities, no edema, no clubbing, no cyanosis Pulses: ++ on all extremities

Musculoskeletal Exam Inspection: Stands erect, no noted lordosis, kyphosis or scoliosis No noted skin changes or subcutaneous nodules, no swelling and masses Extremities: Ulnar devation of both hands No swelling or redness of joints

Musculoskeletal Exam Palpation: No heat tenderness, swelling, fluctuation of joints, crepitus, pain and resistance to pressure to bones and joints Muscle tone is firm Cervical: No direct tenderness, No trigger points, No taut bands, Not warm

Musculoskeletal Exam AROM and PROM (cervical): Limited ROM on Lateral Flexion and Rotation No limitation on Hyperextension and Flexion No pain on shrugging shoulders against resistance and turning head against resistance

Musculoskeletal Exam MMT: 5/5 on all extremities DTRS: ++ on all extremities Spurling’s: negative Hoffman’s: negative Babinski: negativve

Physical Examination Neurologic Examination Mental Status: Conscious, coherent, oriented to time, place and person, follows commands Cranial nerves: Olfaction intact, bilateral pupils 2-3mm ERTL, no visual field cuts, EOM’s full and equal, V1V2V3 intact, can raise eyebrows, smile, frown, puff cheeks, intact gross hearing, uvula midline on phonation, (+) gag reflex, can shrug shoulders, can turn head side to side against resistance, tongue midline on protrusion Motor: no atrophy, no fasciculations, no spasticity or rigidity, MMT 5/5 on all extremities Cerebellar: can do APST and FTNT with ease on both upper extremities Sensory: no sensory deficit Reflexes: DTRs ++ on all extremities, (-) Babinski Meningeal signs: (-) nuchal rigidty, (-) Brudzinski, (-) Kernig’s

CERVICAL STRAIN IMPRESSION

NECK PAIN Trauma Cervical Disk Disease Cervical Spondylosis Others

SymptomsSignsProblem Intermittent neck pain Assymetrical restriction of neck movement Articular Pain in occiput, vertex, scapula, shoulder, and interscapula Pain may occur on shoulder adduction or external rotation, but pain on forced lateral flexion of cervical spine Dural Severe pain in appropriate dermatome Weakness and sensory impairement in affected nerve root distribution, abnormal reflex if necessary Nerve root

Class of symptomDetails Symptoms suggestive of a mechanical cause Intermittent symptoms Pain confined to articular and dural distribution Neurologic features confined to a single root Worrying symptomsConstant or progressive symptoms Neurologic features, bilateral or involving more than one nerve root